Home > Specialized Phone Program > Specialized Phone Program Application Specialized Phone Program Application Step 1 of 8 12% Income EligibilityIf you do not meet the income requirements below DO NOT fill out this application. Please contact the ND Assistive offices at 1.800.895.4728 for other options that may be available to you. Estimated Median Income for North Dakota Fiscal Year 2021 (January 1, 2021 to December 31, 2021)Based upon Administration for Children and Families, Office of Community Services, Division of Energy Assistance, Guidelines updated as of January 20, 2021 Severe Hearing/ Speech/ Physical Impairment Deaf # of Persons in Household Estimated Median Income 150% Estimated Median Income 1 $51,520 $77,280 2 $69,580 $104,520 3 $87,840 $131,760 4 $106,000 $159,000 5 $124,160 $186,240 6 $142,320 $213,480 7 $160,480 $240,720 8 $178,400 $267,600 For each additional person, add $18,160 $27,240 Source: U.S. Department of Health and Human Services Personal InformationName* First Middle Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Other What is your gender identity?* Male Female Transgender - Male Transgender - Female Non-Binary Non-Discolser Other Address* Street Address Address Line 2 City State North DakotaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County* Phone*Phone Type Home Mobile Work Other Email Address Demographic InformationWhat is your Ethnicity?* Hispanic or Latino Not Hispanic or Latino Unknown What is your race?* American Indian/ Native Alaskan Asian Black/ African American Native Hawaiian/ Other Pacific Islander Non-Minority (White, non-Hispanic) White-Hispanic Other What is your Primary Language?* English Other Do you live alone?* Yes No Unknown Do you feel socially isolated?* Yes No Is your income below the national poverty level (see chart below)?* Yes No 2021 HHS Poverty Guidelines Size of Family Unit Poverty Guideline 1 $12,880 2 $17,420 3 $21,960 4 $26,500 5 $31,040 6 $35,580 7 $40,120 8 $44,660 For each additional person, add $4,540 Physical InformationDo you have problems with cognition or memory?* Yes No Do Not Know Do you have problems with dexterity?* Yes No Do Not Know Do you have problems with vision?* Yes No Do Not Know Do you have problems with hearing?* Yes No Do Not Know Do you have problems with speech?* Yes No Do Not Know Equipment QuestionsI have or am in the process of getting land line service.* Yes No Not Applicable I have or am in the process of getting cell phone service.* Yes No Not Applicable I have internet access in my home/residence.* Yes No Not Applicable I have difficulties with (check all that apply)* Hearing on the phone Hearing the phone ring Speaking (being heard or understood) on the phone Holding or picking up the phone Seeing the numbers/ buttons on the phone Dialing the phone Please describe your difficulty using the phone*Do you currently wear a hearing aid(s)?* Yes No Do you have a cochlear implant?* Yes No If you know what equipment you need, please check it below Teletypewriter (TTY) Amplified phone Cordless phone Captioned phone Captioned phone with large display Cell phone adaptation Other Other EquipmentPlease describe other needed equipment. What make and model of cell phone do you currently have? EligibilityI have a severe hearing, speech, vision, and/ or physical impairment that makes using a telephone difficult.* Yes No I currently have or am in the process of getting phone service.* Yes No I have family income under the guidelines given below.*(Assistive reserves the right to request a copy of applicant’s federal tax return at a later date, if needed.) Yes No Estimated Median Income for North Dakota Fiscal Year 2021 (January 1, 2021 to December 31, 2021)Based upon Administration for Children and Families, Office of Community Services, Division of Energy Assistance, Guidelines updated as of January 20, 2021 Severe Hearing/ Speech/ Physical Impairment Deaf # of Persons in Household Estimated Median Income 150% Estimated Median Income 1 $51,520 $77,280 2 $69,580 $104,520 3 $87,840 $131,760 4 $106,000 $159,000 5 $124,160 $186,240 6 $142,320 $213,480 7 $160,480 $240,720 8 $178,400 $267,600 For each additional person, add $18,160 $27,240 Source: U.S. Department of Health and Human Services ContactWould you prefer if we contact someone else regarding your application? Yes No Contact Name First Last Relationship with Applicant Contact PhoneContact Email How did you hear about this program?* Brochure Newspaper TV ad Internet ad Radio ad Word of mouth Assistive website Presentation Doctor AcknowledgmentThe preceding facts I have provided are true and complete to the best of my knowledge. (If under 18, applicant and parent/ guardian must sign.)Applicant SignatureApplicant Signature*Please type full name Parent/ Guardian/ Power of Attorney Signature (if applicable)Parent/ Guardian/ Power of Attorney SignaturePlease type full name. Condition of Acceptance of Telecommunications DeviceUse and Care I agree to protect this equipment against damage caused by dust, dirt, weather, and physical abuse. Damage If the equipment is damaged, I will not try to take it apart. I will return the equipment to Assistive. Theft If the equipment is stolen, I will report it to the police. A copy of the police report must be given to Assistive before I can get replacement equipment. Loss If I lose my equipment, I must report the loss to Assistive. I understand that I may not receive replacement equipment. Travel I understand that this equipment is the property of the State of North Dakota. I can travel out of North Dakota with my equipment for short trips and vacations. Any out-of-state travel with my equipment for more than 90 days requires written permission from Assistive. Change of Address If I move to another place in North Dakota, I have ten (10) days to report my new address to Assistive. If I plan to move to another state, I must return the equipment to Assistive. This must be done before I leave North Dakota. I understand that if I do not return this equipment, I may be charged with a misdemeanor or felony theft charge according to the ND Century Code 12, 1-23-07. State Property I understand that this equipment is property of the State of North Dakota and as such, I will not sell it. I will not give or loan it to others not in my immediate family. If I sell my equipment, I can be criminally prosecuted. Liability I agree to accept responsibility for said equipment and all claims, damages, and/or expenses caused by the use or misuse of said equipment by myself or anyone else. Denial If I do not keep these terms of conditions of acceptance, I can be denied the privilege of having telecommunications equipment provided by the State of North Dakota. Death In the event of my death, the executor or other responsible party must return the equipment to Assistive within thirty (30) days. Repair Assistive is responsible for all reasonable expenses to maintain and repair my equipment. If my equipment is damaged, lost, or destroyed because of negligence or abuse, I must pay for replacing or repairing the equipment. Having read the above and conditions and having them explained to me I agree to comply with all of the conditions.Applicant SignatureApplicant Signature*Please type full name Parent/ Guardian/ Power of Attorney Signature (if applicable)Parent/ Guardian/ Power of Attorney SignaturePlease type full name. Questions? Please call: Toll-free: 1.800.895.4728 Local: 701.258.4728 You may also email TEDS at:firstname.lastname@example.org This project is supported by funding granted through the North Dakota Department of Human Services, Aging Services Division.CommentsThis field is for validation purposes and should be left unchanged.